GW1-2021-01567_Well Construction - GW1_20210309

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple welkEC E Iv E D
1.Well Contractor Information:
Kolby Sawyers 1AAR X 9 2021 FR MATE TO R ZONES DESCRIPTION
Well Contractor Name ft. ft.
4471 A Information Processing Unit ft. ft.
NC Well Contractor Certification Number
pV'JR Section 15.OUTER CASING for mulfi-cased wells OR LINER if dj" icable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 rt. 168 16.25 #21 1 PVC&Steel
Company Name I&INNER CASING OR TUBING .eotbermal closed-loo
EH2O807 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County State,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in'
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft. ft. in•
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT .
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 It. 20 ft. Bentonite Pumped
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 49.SAND/GRAVEL PACK(if applicable).
❑Aquifer Storage and Recovery ❑ FROM TO MATERIAL EMPLACEMENT METHOD
Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
ft. ft.
.20.:DRILLING LOG attachadditional sheets if necessa 1
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/mck type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 168 ft. OVER BURDEN
11-19-2020 168 fit- 265 ft• GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft.
George & Laura Haug ft. ft.
Facility/Owner Name Facility ID#(ifapplicable)
ft. ft.
King Stepp Road Mill Springs, NC
Physical Address,City,and Zip
21.REMARKS,—
Polk P51-56 Installed 147ft.of PVC Casing&21ft of'Steel Casing
County Parcel Identification No.(PIN) Put Steel at the bottom
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one lat/long is sufficient)
N W Kh& ,��..(� 1-6-2021
Signature ofCertifie l Con actor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the well(,)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy ofthis record has been provided to the well owner.
q this is a repair,fill out known well construction information and explain the nature of the
repair ender 21 remarks.section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
Vor nudtiple injection or non-water.supply wells ONLY with the same construction,you can
suhmit one form SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 265 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
hor multiple wells list all depths ifdierent(example-3@200'and 2@ 100') construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
/fhaterlevel is above casing,use"!- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
ROTARY 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 8 Method of test: RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: PILLS Amount: 20 well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013